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The report below is of the State Medicaid Managed Care Advisory Committee which met today for a regular meeting to hear presentations regarding Medicaid issues.
 
Medicaid Quality Activities Presentation

  • The following entities work in the area of quality assurance
    • External Quality Review Organization (EQRO) performs three CMS required functions:
      • Performance improvement validation
      • Performance measure validation
      • MCO compliance review
    • HHSC Performance Operations deal with:
      • Program management
      • Finance
      • Health plan management
  • A combination of state developed and nationally recognized quality measures are used including HEDIS, AHRQ, 3M potentially preventable events and the CAHPS survey
  • Quality initiatives
    • Performance improvement projects
      • Projects are based on recommendations by EQRO which are developed using MCOs’ previous year’s performance
      • HHSC selects two topics and each MCO develops their own projects
      • MCOs are required to follow CMS and EQRO protocols when conducting their projects
    • Quality assessment and performance review projects
      • Developed by each MCO based on state and federal standards
    • Pay for quality program
      • Based on SB 7 (83R)
      • Provides financial incentives and disincentives based on incremental improvement
      • Positive and negative points are assigned based on quality measure performance year to year
      • Payments to MCOs can be given up if performance doesn’t meet standards
      • Dental plans have a similar program; they are evaluated and money is placed at risk but there aren’t incentives as in the MCO program
    • MCO report cards
    • Nursing facility quality programs
      • HHSC and DADS are developing quality indicators to measure quality of care in nursing facilities to incentivize MCOs
      • The nursing home carve-in has been delayed until March 1, 2015
    • Long-term services and supports workgroup
      • Convened in the Fall of 2013 to develop measures to evaluate the quality of home and community-based long-term services and supports

Administrative Simplification Presentation

  • SB 1150 (83R) requires HHSC to develop a provider protection plan
  • In the Fall of 2013 HHSC sent out a stakeholder survey and received over 200 responses regarding issues providers have with MCOs
  • Most provider issues dealt with claims processing, credentialing, standardizing of forms and prior authorizations
  • HHSC recently gained final approval to send out invitations for workgroup participation
  • The first meeting will be April 24, 9:00 AM at the Brown-Heatly building
  • The workgroup will not focus on standardizing prior authorization forms; Texas Department of Insurance is spearheading that initiative

 
Network Adequacy Presentation

  • MCOs are limited in the providers they can contract with because they must be state Medicaid providers
  • By statute, MCOs must meet a number of federal and state standards including having sufficient capacity to serve the expected enrollment; federal regulations do not specify time and distance coverage standards
  • SB 7 requires the Medicaid Managed Care Advisory Committee to provide recommendations and input on implementation and operation of provider adequacy
  • There are distance requirements so that there must be a certain number of providers within a radius of the members’ residences; there are separate standards for pharmacies; distances vary between rural, urban and suburban clients
  • There are thresholds for each quarter that each MCO may not exceed regarding out of network services
    • There is an exception that if an MCO is making a good faith effort to contract with a provider that is out of network, those services possibly may not count toward their out of network percentage
  • 1115 waiver reporting requirements for network adequacy state that HHSC must submit reports documenting network adequacy during readiness reviews, as well as quarterly, annually and if any major changes in the MCO contract are made
  • Network adequacy analysis is done using GeoAccess maps, MCO reports, enrollment broker reports, care complaints and out of network usage reviews
  • Committee members discussed other standards that may be beneficial in determining network adequacy such as wait time for appointments and whether or not an in-network provider is still taking new patients
    • Rudy Villarreal with HHSC noted that there is language in the contract regarding timeframes for appointments that is the same across the board for MCOs; also, health plans do their own research determining whether providers in their network are available; it benefits MCOs to have sufficient network adequacy because quality payments are at stake when outcomes are poor
  • A member suggested that the SB 7 language regarding home and community-based long-term services and supports be included in the HHSC rule and in future MCO contracts
  • A member suggested that a future agenda item should focus on whether the legislature is appropriating sufficient funding to incentivize providers to serve new Medicaid clients

 
Public Comment
Carol Smith, Private Provider Association of Texas

  • Would like to ensure there is access to care for IDD clients who need acute care services and that the care is easy to find; many clients have to call a significant number of providers before they find one who can provide care

 
Helen Kent Davis, Texas Medical Association

  • Specialty care network adequacy is one of the top complaints from primary care physicians trying to find specialty care for their patients; this is a significant barrier to participation for providers